Basic Information
| Provider Information | |||||||||
| NPI: | 1114378957 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBB | ||||||||
| FirstName: | DERRICK | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15720 E 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990379477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097607958 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1590 E POLSTON AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087774242 | ||||||||
| FaxNumber: | 2087774020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2016 | ||||||||
| LastUpdateDate: | 06/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-4754 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.